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Oct 2 fi 2 03:48p 763-213-0695 p,3 <br /> " G <br /> P perty address: � �,�� Inspector initials/Date: ��G' ^ �-',� ��-- <br /> ���_� <br /> 1 Impact On Public Hedith—Compliance component#1 of 5 <br /> Com liance c�iteria: Verificatian method(s): <br /> System discharge sewage to the �Yes �] N� .��� 5earched for svrface outlet <br /> round suriace. Seasched for seeping in yard/backup in home <br /> ❑ Excess�ve ponding in soil systemlD-boxes <br /> Sysiem discharge sewage to drain tile ❑ Yes (�(No � Homeowner teslimony(See Comments/Fxplanation) <br /> or surFace waters. <br /> ❑ "Black soil" above soil dispersal system <br /> System cause sewage bacicup into ❑Yes [�No „ <br /> dwelfing or establishment. ❑ System requires°emergency pumping <br /> Any"yes"answer above indicates the system is � Performed dye test <br /> ❑�Unable to venfy(See Camments/Explana6on) <br /> an/mminent Threat to Public Healtf�and Safety. ❑ Other meihods not listed (See Comments/Fxp�anation) <br /> C om me ntslExpla nat i o n: <br /> 2 Tank Integrity—Compliance component#2 oF 5 <br /> Com liance criteria: Verification metF�od�s�: <br /> Systern consists of a seepage pit, ❑Yes � I�o � Probed tank(s)bottom <br /> cesspool,drywell, or leaching pit. (� Examined consirudion recQrds <br /> Seepage pits meeting 7080.2550 may be , �, Exarnined TaRk Integl�ly ForrY�(Attach) <br /> com Uanf i/aflowed in local oio'inance. <br /> Sewage lank(s)leak below their ❑Yes [� No � Observed liquid level below operating depth <br /> desi ned eralin de ih. � Examined empty(pvrnped)tanks{s) <br /> If yes,which sewage fiank(s) leaks: ❑ Probed ouiside fank(s)for"black soil' <br /> ❑ Unable to verify fSee Comments/Expfanation) <br /> Any "yes"answer above indicates the � pther melhods not listed(See Comments/Explana6on) <br /> system is Failing to Protect Groundwater. <br /> Comments/Expl anation: <br /> i <br /> i <br /> 3. Othe� Compliance COrlditiOns—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cradced, unsecured,or appear to stnx6urally unsound. ❑Yes• J$� No ❑unknown <br /> b. Other issues(eleciricalirazards.,et�.)to immediately and ad�ersely impacl public health or safety. ❑Yes* Q�No ❑unknown <br /> `System is an immirrent threat to public hea/�h and safety <br /> Explain: <br /> c. System is non-protedive of ground water for other conditians as determined by inspector ❑Yes• �No <br /> *System fs fai/ing to protect groundwater <br /> Expfain: <br /> I <br /> .pca.state.mn.us • 65t-296-6300 • 800-657-3864 • TTY 651-282-5332 or 8U0-657-38b4 • Available in aitemative formats <br /> wn-�vwic�c4-31 . 1r�e117 .. ., .,, <br /> I <br />